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Case History

Image not available. You are seeing a 76-year-old man who was diagnosed with non-small cell lung cancer 4 months ago. He had lung metastases and small-volume liver metastases at the time of diagnosis. He was initially treated with three cycles of chemotherapy, which was stopped due to a lack of clinical response. He now presents to the oncology clinic with moderate right-sided chest pain, which is present most of the time despite regular paracetamol.

What approach would you use for the treatment of his pain?

What do you need to do if the pain does not respond to this initial approach?

If investigations confirm bone metastases what other treatments should be considered?

Background

What approach would you use for the treatment of his pain?

Image not available. Pain occurs in approximately 70% of patients with advanced cancer, but can be controlled in about 80% using the simple stepwise approach of the World Health Organization (WHO) analgesic ladder (Figure 53.1).1 The first step in assessment of pain is always to take an accurate pain history including site, severity, nature and radiation of pain, any exacerbating or relieving factors and any psychosocial or spiritual factors which may be affecting the pain. It is important to know which analgesics have been tried, their effect on the pain and any adverse effects they have caused. Many patients have a fear of opioids, which may need to be explored further before starting treatment.

Figure 53.1

World Health Organization three-step analgesic ladder.

The three-step WHO analgesic ladder is the mainstay of the approach to analgesia. The severity of pain and previous analgesic exposure dictate the strength of analgesia to be used. Analgesia should always be given regularly (by the clock), orally if possible (by the mouth) and using the logical stepwise approach (by the ladder). At each step of the ladder, co-analgesics can be added depending on the nature and pathophysiology of the pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and steroids can be helpful in cancer pain, especially pain associated with bone metastases and soft tissue inflammation, although the risk of serious adverse effects needs to be considered. The addition of paracetamol to weak or strong opioids may give additional benefit, but this needs to be weighed against the tablet burden. Neuropathic pain and its treatment are discussed in Chapter 54.

This patient has already tried regular paracetamol without effect, so needs to move up to step 2 of the ladder. Codeine is usually the weak opioid of choice and can be used in combination with paracetamol as co-codamol (30/500), two tablets four times a day, without increasing the tablet burden. At this dose the patient will be taking 240 g of codeine a day. Above this dose there are more undesirable ...

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